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Jefferson County Special Needs Registry Application The purpose of the Jefferson County Special Needs Registry is to provide emergency responders with important information from individuals that may require assistance duringan emergency, (e.g. hurricane, flood, blizzard, power-outage and/or disease outbreak). Thisprogram is voluntary and individuals on the registry may decide whether or not to accept assistance. Completion of this form in no way ensures that the individual completing this form will receive immediate or preferential treatment in an emergency. Individuals should maintain a personal emergency plan. Personal Information PLEASE PRINT CLEARLY Date of Application: □ New Application □ Update of Previous Application Last Name First Name MI Date of Birth: Gender: Street Address Apt. # City Zip Primary Phone Alternate Phone E-mail Address (optional): Mailing Address (If different) City Zip Name of Subdivision, Mobile Home Park, Apt. Building, etc.: Living Situation (check one): □Live Alone □With Spouse/Partner □With Children □With Parents □ Other Primary Language: Do you need the assistance of a translator for English? □Yes □No For the Hearing Impaired: Do you use sign language: □Yes □No TTD/TTY Medical Information (Check those that apply to your medical condition.) □Hearing/Visual/Speech Impaired (circle one) □Memory/Mentally Impaired (specify condition) □Developmentally Disabled □Bedridden □Wheelchair Bound □Walker or Cane (circle one) □Weight in excess of 400 pounds □Bariatric needs □Ongoing contagious condition (specify) □Allergies (specify) □Seizures □DNR/Living Will (circle one) □Special Dietary Needs* (specify) *If you require a special diet, be prepared to bring with you the appropriate foods. □I.V. Medication □Injections □Refrigeration for Medication □Insulin Dependent □Wound Care □Incontinence Supplies □Ostomy Care □Suction □G-tube or NG-tube Feeders (circle one) □Dialysis □Portable Oxygen Tank □Oxygen Concentrator/Ventilator (circle one) □Continuous □Intermittent (check one) □Sleep Apnea Machine □Pace Maker/Defibrillator (circle one) Any other required or life-sustaining equipment or medication: Medication Management: You are strongly encouraged to prepare an emergency kit with necessary medical supplies and to keep in that kit an updated list of necessary medications. For information on preparing an emergency kit, please visitwww.Ready.gov or www.RedCross.org. ---PAGE BREAK--- Emergency Contact Information PLEASE PRINT CLEARLY In-State Emergency Contact Last Name First Name Relationship Phone Out-of-State Emergency Contact Last Name First Name Relationship Phone Medical Provider Information (Fill in all thatapply) Physician Name Phone Pharmacy Name Phone Home Health Care Agency Name (or personal caregiver) Phone Respiratory Equipment Provider Name Phone Transportatio n Information Geographic Location: □ Flood Plain □ Isolated/Difficult to Reach □Storm Surge Zone □ 10 Mile Nuclear Zone □ Mobile Home Can you, a family member or friend provide you with transportation to a shelter in an emergency? □ Yes □ No If you need assistance with transportation, check one of the following: □ Able to Ride in Car □Van with wheelchair lift □ Able to ride Bus/Taxi □ Ambulance required Pet Information*: Do you have pets that would require special attention if you were asked to evacuate your home? If so indicate the number of Service Animal Dogs Cats Other (Describe other) *Pets may not be able to accompany you to the shelter. Individuals are responsible for caring for the needs of an assistance animal, including bringing food and other essential needs to the shelter. Service animals are allowed in shelters but must provide proof of current rabies vaccine. Emergency Planning In case of an emergency, do you plan to: (Place an X beside the one that applies.) 1. Stay with family or others? 2. Stay at home? 3. Evacuate to an appropriate facility, independently? 4. Evacuate to an appropriate facility with caregiver? Authorization Information By signing and submitting this form, I/legal guardian agree that my name be added to theJefferson County Special Needs Registry. In the event of an emergency I hereby authorize the exchange of information between Jefferson County Emergency Services and the individuals and agencies listed on this form. I grant emergency responders permission toenter my home following an emergency event or disaster situation, if necessary, to assuremy safety and welfare. Applicant Signature Date X Authorized Guardian Signature Date X Return Completed Forms to: Jefferson County Emergency Services Attn: Special Needs Registry, P. O. Box 658 Louisville Georgia 30434